Accident / Incident Report Form

PART 1  INITIAL NOTIFICATION

Report Number:

1.  General information

Date of incident

Time

Platform/Location 

Specific area/site

Contract No.

Rev

0

2.  Person involved

Trade

Employer

3.  Short description of event

What happened?

What was the injury / damage?

4.  Immediate action taken as a result of the accident / incident

5.  Provisional Category

Type Of Case

Injury            

Classification  

Illness           

Fatality

  DAFWC /

Over 1 Day Lost Time

Restricted Work

Medical Treatment

First Aid

Non-Injurious

Damage

Near Miss

Environmental

Hydrocarbon Release

6.  Type of Incident

Work Related

Off-duty

Travel

Potential Matrix Factor

                   Injury

                    Loss

                    Env

see section

    16

7.  Medical / Compassionate Evacuation

To (Location)

Patient Escorted

Yes/No

Patient to be met

Yes/No

Project / Duty HR Representative informed

Yes/No

8.  Initial Notification by

Print Name:

Sign:

  Date:

PART 2 INVESTIGATION & REPORT

9. Injured person

Forename(s)

Surname

Date of Birth

Gender

Address:

10.  Witnesses

Name

Address

Employer

11.  Investigation Team

Name

Title

Employer

Leader

Member

Member

Member

Member

12.  Full description of Incident (Use additional sheet if required)

13.  Details of physical injury (where applicable)

Injury Location (tick one box only)

Nature of Injury (tick one box only

Head

Finger

Crush

Whiplash

Face / Neck

Leg / Hip

Fracture

Foreign Body

Eye

Ankle

Dislocation

Asphyxiation/Gassing

Chest

Foot

Puncture

Ingestion

Abdomen

Respiratory System

Cut/Laceration/Abrasion

Burn/Scald

Back

Digestive System

Strain/Sprain

Electric Shock

Arm / Shoulder

General

Bruising/Swelling

Ill Health

Wrist

Multiple

Shock/Concussion

Multiple

Hand

Not known

Loss of Consciousness

Other

Internal Damage to Organs

Not known

14.  Incident Category / Type  (Tick one ‘CATEGORY’ and one ‘Type’ relevant to that Category.)

FALLS / SLIPS

PLANT / EQUIPMENT

WORK ENVIRONMENT

COLLAPSE/ OVERTURN

Same level

Non-powered hand tools

Stepping on/striking against

Excavation

Less than 2 meters

Portable power tools

Falling/flying object

False work

More than 2 meters

Fixed power tools

Exposure to substance/

Structure

Down stairs/steps

Powered plant

Asphyxia/drowning

Plant

Non-powered plant

Struck by moving vehicle

Stacked material

MANUAL HANDLING

ENVIRONMENTAL

Electricity

Equipment

Release (Air/Sea/Land)

Fire/explosion/hot material

OTHER

Materials

Contained Release

15.  Prime Cause  (Tick one ‘CATEGORY’ and one ‘Type’ relevant to that Category.)

PLANT / EQUIPMENT

PPE

HUMAN FACTORS

WORK ENVIRONMENT

Construction/design

Design

Failure to follow rules

Defective workplace

Installation

Wrong type used

Instructions misunderstood

Poor housekeeping

Safety device

Maintenance

Error of judgment

Lighting

Operation/use

Not provided/unavailable

Lack of experience

Weather

Mechanical failure

Not used

Unsafe attitude

Design/Layout

Maintenance

Undue haste

Lack of room

MANAGEMENT

Horseplay

Noise/Distraction

System of work

Fatigue

Supervision

Working without authorization

OTHER

Training

Third Party

Communication

Other (specify)

16.  Potential Matrix Factor & Investigation Level

Cost - £

<1k

1-10k

10-100k

100k-1M

1M+

No. Of people at risk

0

1

2-10

11-100

101+

Injury

Loss

Environment

1

1

1

2

2

2

First Aid – Negligible Injury; No absence from work

Minor loss/damage/ business impact

Minimal reversible environmental impact

2

1

1

2

2

2

Medical Treatment – Minor injury treated by Medic/GP

Moderate loss/damage/ business impact

Minor pollution with short term impact

3

2

2

2

2

3

Lost Time – Injury leading to lost time

Significant loss/damage/ business impact

Moderate pollution with medium term localized impact

4

2

2

2

2

3

Serious Injury – permanent disability

Severe loss/damage/ business impact

Severe pollution with long term localized impact

5

2

3

3

3

3

Fatality - death

Major loss/damage/ business impact

Major pollution with long term environmental change

A

B

C

D

E

PART 3 ACTIONS, LATERAL LEARNING  & FOLLOW-UP

17.  Corrective Actions (To address the ‘Prime Causes’ identified in section 15.)

Person responsible

Task

Target Date

Status

18.  Reference to associated witness statements, drawings, risk assessments, permits, photographs, tool box talks etc.

19.  Report completed by

Senior Site Rep.

  Date:

20.  Approval of report and corrective actions

HSE Advisor

Print Name:

  Date:

Head of Dept

Project Manager

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